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Child abuse is a serious concern that can cause the death of a child. In such cases the medico-legal evidence is often pivotal but complex, drawing across multiple medical disciplines and techniques. One key specialism is histopathology, which is considered the gold standard for estimating the age of individual fractures. Another is micro-CT imaging, which can visualise the location of trauma across the body. This case report demonstrates how micro-CT was used to contextualise the histological evidence in the Criminal Justice Proceedings of a fatal child abuse case. This was achieved by overlaying the aged fracture evidence from histopathology onto the visuals rendered from micro-CT imaging. The case was a suspected child abuse of a deceased 1-month old infant who was reported unresponsive by their parents. The child was taken to hospital where they were pronounced dead. Suspicion was raised and post-mortem imaging confirmed head trauma and rib fractures, and the case was escalated for a forensic investigation. This case report details how the micro-CT imaging was merged with the gold standard of histopathology for visualisation of trauma, and how the court presentation was planned alongside Senior Investigating Officers and various medical experts. The presentation was used in court by the histopathologist to present the evidence. The resulting presentation provided additional clarity to jury members regarding the location, severity, frequency, and timings of the injuries. From the perspective of the investigating police force, the resulting presentation was crucial in ensuring understanding of the medico-legal evidence of how the infant died. The prosecuting lawyer noted that combining the histological and micro-CT evidence in this way allowed the evidence to be presented in a sensitive, clear, and impactful manner., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

The estimation of the post-traumatic survival time (PTST) in case of bone injuries remains a tricky issue in the forensic field, especially when dealing with dry bones. Newer high-resolution imaging, and in particular microcomputed tomography (micro-CT), has the potential to significantly improve our abilities to interpret antemortem and perimortem lesions and accurately date fractures in a less destructive analysis. In this paper, nine costal fractures of known post-traumatic ages were analyzed through gross examination, conventional radiography, and microcomputed tomography, in order to test the potential of microcomputed tomography for dating fractures. As a result, microcomputed tomography provided images of high quality and definition and allowed the observation of the internal microarchitecture of the fractures and calluses. While microcomputed tomography cannot substitute histological examination for the estimation of the post-traumatic survival time, it constitutes a potent and helpful complementary tool for the analysis of bone trauma., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Rib fractures represent a common injury type due to blunt chest trauma, affecting hospital stay and mortality especially in elderly patients. Factors promoting rib fragility, however, are little investigated. The purpose of this in vitro study was to explore potential determinants of human rib fragility in the elderly. 89 ribs from 13 human donors (55-99 years) were loaded in antero-posterior compression until fracture using a material testing machine, while surface strains were captured using a digital image correlation system. The effects of age, sex, bone mineral density, rib level and side, four global morphological factors (e.g. rib length), and seven rib cross-sectional morphological factors (e.g. cortical thickness, determined by μCT), on fracture load were statistically examined using Pearson correlation coefficients, Mann-Whitney U test as well as Kruskal-Wallis test with Dunn-Bonferroni post hoc correction. Fracture load showed significant dependencies (p < 0.05) from bone mineral density, age, antero-posterior rib length, cortical thickness, bone volume/tissue volume ratio, trabecular number, trabecular separation, and both cross-sectional area moments of inertia and was significantly higher at rib levels 7 and 8 compared to level 4 (p = 0.001/0.013), whereas side had no significant effect (p = 0.989). Cortical thickness exhibited the highest correlation with fracture load (r = 0.722), followed by the high correlation of fracture load with the area moment of inertia around the longitudinal rib cross-sectional axis (r = 0.687). High correlations with maximum external rib surface strain were detected for bone volume/tissue volume ratio (r = 0.631) and trabecular number (r = 0.648), which both also showed high correlations with the minimum internal rib surface strain (r =  - 0.644/ - 0.559). Together with rib level, the determinants cortical thickness, area moment of inertia around the longitudinal rib cross-sectional axis, as well as bone mineral density exhibited the largest effects on human rib fragility with regard to the fracture load. Sex, rib cage side, and global morphology, in contrast, did not affect rib fragility in this study. When checking elderly patients for rib fractures due to blunt chest trauma, patients with low bone mineral density and the mid-thoracic area should be carefully examined.

Background: Spontaneous rib fractures, especially in association with chest wall herniation, represent an uncommon pathology. As such, there are little data analyzing approaches to treatment or regarding the success of intervention. The goal of this study was to analyze our cumulative experience with this unusual condition., Methods: A case series of 12 patients was gathered from a single institution based on outpatient visits between February 2015 and October 2018. Each chart was retrospectively reviewed with particular attention to age, gender, BMI, area of injury, and smoking history. Patients presented with complaints of dyspnea or pain related to rib fractures with or without intercostal neuralgia. Each of these patients was noted to have rib fractures with lung herniation either on imaging, outside hospital records, or physical exam. A thorough medical history was obtained with attempts to find common predisposing factors as well as data regarding any previous surgical intervention for their herniation., Results: Nine of the 12 patients reviewed had recent or prior surgical intervention. Every patient seen in the clinic with a spontaneous fracture and herniation incidentally had a BMI >30 and was therefore classified as obese. Additionally, every patient who had a recurrence after their first surgical attempt at repair had a BMI greater than or equal to 35. All 12 patients seen at our institution were males. The failure rate of operative intervention was 66%., Conclusions: Obesity was a prevalent comorbidity in the patient population we reviewed. Given the role obesity plays in abdominal and hiatal hernia repair success rates, it should be considered that obesity is a significant contributor to chest wall herniation if rib fractures occur. With 66% chest wall repair failure, patient selection is critical in the success of surgical intervention. Perhaps additional patient optimization, especially weight loss, should be considered prior to surgery.

Aims: To describe whether haemorrhage into the fracture gap, bone marrow, or periosteum, and loss of osteocyte nuclei from infant rib fracture margins, are true markers of vitality or may be seen solely as a consequence of cardiopulmonary resuscitation attempts., Methods and Results: A description is provided of histological findings in sampled rib fractures in a retrospective consecutive series of infants, aged 1 month to 1 year, who suffered sudden death. All had undergone cardiopulmonary resuscitation (CPR) and were investigated by use of skeletal survey, whole body computed tomography (CT), and invasive postmortem (PM). There was no suspicion of child abuse. 15 infants were studied, 9 of whom had anterior/anterolateral rib fractures; slides were available with consent for use in seven. Skeletal survey identified no fractures. CT and PM showed 46 fractures, 27 of which were examined histologically. Marrow cavity haemorrhage> 2 mm in diameter was seen in 55% of fractures; easily identifiable red cells were seen in the fracture gap in 36%, and beneath the periosteum in 36%. Loss of intact osteocytes from lacunae in bone fragments at the fracture margins relative to distant areas was obvious in 50% of fractures., Conclusions: Anterior rib fractures, visible on CT and histologically, are common after CPR in infants. Empty lacunae and bleeding into the fracture gap, into the marrow cavity and beneath the periosteum are all frequent in CPR-related infant rib fractures, and should not be used to discriminate between true in-vivo injury and perimortem injury., (© 2020 John Wiley & Sons Ltd.)

Cut marks provide essential knowledge to interpret which and how tools were used, both in archaeological and forensic context. Lots of studies focused on experimentally produced cut marks on animal models to develop methods for stabbing incidents. However, animal models are criticized to be morphologically different in comparison to human bones. This study analyzed the bone composition and experimentally obtained cut marks done on ribs from humans, pigs and goats. Methods included a qualitative description of differences between the species and a quantitative analysis of the cut mark proportions in histological thin sections and micro CT scans. The results indicated that especially the cortical bone of non-human ribs was different in comparison to human bone tissue as they were more robust and usually juvenile. Plexiform bone dominates and remodeled lamellar bone is rarely visible. The knife impact tends to create debris inside the cut mark and stress fractures along lamellae and cement lines perpendicular to the cut mark. Moreover, entheses of the intercostal muscles are always affected by the incision. Pig ribs were shown to be better suited as a model for sharp force trauma than goat ribs in comparison to humans. Though, plexiform bone and non-remodeled bone made it not quite ideal. We suggested to use bone material from animals used for breeding instead of meat production as they are slaughtered at higher ages., Competing Interests: Declarations of Competing Interest None., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Forensic application of 3D scanning and printing technology is gaining momentum with 3D printed evidence starting to be produced for court. However, the processes for creating these forensic 3D models requires still rigorous assessment to ensure they adhere to the relevant legal standards. Although, previous work has examined the accuracy of 3D prints created from medical grade Computed Tomography (CT), no such assessment has been carried out for Micro Computed Tomography (micro-CT) which offers superior resolution and the ability to capture forensically relevant injuries. This study aimed to quantify the error rates associated with forensic 3D printed models and toolmarks, created using three different printing technologies, based on micro-CT data. Overall, 3D printed models, based on micro-CT scans, replicate bone surface geometry to sub-millimetre accuracy (<0.62mm for overall shape and <0.36mm for toolmarks). However, there were significant differences between the printing technology employed (mean errors of -0.3%, -0.8%, and 0.7% for shape geometry and -0.8%, 14.1%, and 0.7% for toolmark geometry for Printers 1-3 respectively). Where possible, the authors recommend micro-CT imaging for producing forensic 3D printed bone models particularly when injuries are present., Competing Interests: Declaration of Competing Interest The authors report no declarations of interest., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Rib fractures are a common finding in legal medicine and information on the impact mechanism is relevant for trauma reconstruction. This study focuses on morphological characteristics of rib fractures resulting from direct or indirect force. Fresh human ribs (n = 312) were divided into two groups and broken through local force (direct) and bending (indirect) in anterolateral areas. The ribs were macerated, visually investigated and the results statistically analysed. The indirect fractures showed a significant larger lateral offset of the internal and external fracture ends while the fracture ends of the direct fractures were more often straight, in line. Also, the morphology of the inner and outer fracture edges was significantly related to fracture type. Direct fractures mostly had rough and jagged inner edges (tension side) and straight, smooth outer edges (compression side), whereas indirect fractures more often showed the characteristics vice versa. The results were more convincing in combination and in ribs from persons aged ≤ 75 years at death. In summary, the direct and indirect rib fractures showed significantly different characteristics regarding orientation and offset of the fracture lines and roughness of the inner and outer fracture edges, which can be helpful to distinguish the traumatizing impact mechanisms in forensic autopsy routine.

The use of postmortem computed tomography (CT) has been described in many articles concerning gunshot injuries. Postmortem magnetic resonance imaging (MRI) for better assessment of soft tissue injuries has also been mentioned in the literature, albeit much less often. The use of postmortem MRI for abdominal gunshot wounds has not been previously presented in the literature. The present case report describes the findings of an abdominal gunshot wound detected by postmortem CT and MRI, followed by an autopsy. The main imaging findings on CT were a hyperdense ring at the entrance wound, which indicated the muzzle imprint mark, a hyperdense region beneath the skin, which was suggestive of combustion residue, gas cavities surrounding the bullet path, which might be related to the temporary cavity, and a fracture of the 13th rib on the left. Magnetic resonance imaging provided a clear depiction of defects in the muscle tissue and peritoneal fat, as well as an injury to the left kidney and a large volume of blood in the abdominal cavity. Computed tomography combined with MRI provided a descriptive presentation of the intracorporeal trajectory noninvasively. Autopsy confirmed the radiologic findings but additionally revealed further relevant findings, which were not detected radiologically, such as a duodenal perforation. Autopsy also detected subendocardial hemorrhages and shock kidney, which were consistent with severe blood loss.The imaging findings and their interpretations are discussed in this case report, as well as the role of CT and MRI in the assessment of abdominal gunshot wounds compared with autopsy.

Blunt renal artery injury (BRAI) is a rare finding with incidence ranging from 0.05% to 0.08% among blunt abdominal trauma patients. BRAI occurs in 1% to 4% of patients with renal injury, and the most common cause is motor vehicle accidents. An unusual case of BRAI in a 47-year-old man at work is reported. The victim accidentally fell from a scaffold (approximately 3 m in height). He was transported to the hospital where he was intubated, but he died after 30 min despite the cardio-pulmonary resuscitation. Surveillance cameras showed the man falling from the scaffold, but his impact with the ground was not captured. At autopsy, except for an oval bruise on the left hypochondrium, no external injury was found. The same mark was noticed on the shirt worn by the victim. Bilateral ribs fractures were found. The abdominal cavity was filled with 2 l of fresh blood and clots as a consequence of a complete transection of the left renal artery. Investigation of the workplace revealed a partial footprint on the external side of the scaffold, matching shoes worn by the victim. On the ground, a metallic pedestrian gate with a 1 m high post was found placed just below the scaffold. It was concluded that the man hit the gate's post as intermediate impact after the fall, which caused the oval bruise, ribs fractures, and the rupture of the left renal artery without injury of the internal organs.

In antemortem fractures, the estimation of the amount of time that has lapsed between the traumatic event and eventual death (the socalled 'posttraumatic survival time' or PTST) can have substantial implications in legal proceedings. It might for instance help to corroborate witness testimonies, to reconstruct the chain of events leading to eventual death or to establish a sequence when multiple traumata in a single individual are encountered. However, PTST estimation of bone trauma is impeded by a myriad of theoretical and practical issues, and is therefore almost invariably considered challenging. A few years ago, a method that combines radiological and histological analysis of fractures to estimate the minimum amount of lapsed PTST in skeletonized remains was proposed. This study aims to test its accuracy on a set of five rib fractures and four skull lesions fractures with known and varying amounts of posttraumatic survival time. In addition, it explores the differences between the assessment on ribs and skull bones and it expands on the proposed method by including computed tomography (CT) scanning. Using conventional radiology and histology, the minimum amount of PTST was accurately estimated in 8 out of 9 of the cases (89%). The one discrepancy between the estimated and known PTST was minimal, being just one day. The precision of the method diminishes as healing advances. It was noted that skull lesions showed less advanced and less well-developed healing features than the lapsed PTST would suggest. Of the three used modalities, conventional radiology proved to be the least accurate. CT scanning proved to be a valuable, sometimes even superior alternative to conventional radiology. Histology was superior to both conventional radiology and CT scanning. The results of our study illustrate the potential of the combined application of radiology and histology to estimate the PSTS in skeletonized human fractures., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Cardiac injury following blunt chest trauma is common in motor vehicle accidents due to a crush or blast injury. Severe cardiac trauma is associated with a very high mortality. If a cardiac injury develops several weeks after non-penetrating chest trauma, establishing a causal link between the traumatic event and the cardiac injury becomes complicated. This article reports a case of fatal delayed hemopericardium and hemothorax following a motor vehicle accident including blunt chest trauma 34 days prior to death. The cardiac injury was caused by displacement of a sharp irregular fragment of one of the decedents fractured ribs and the primary defect was sealed by blood clots. Subsequent bleeding occurred when the thrombus was displaced. Since the incidence of blunt high-energy chest injuries is relatively high, heart and large vessel injuries must be taken into account and a comprehensive examination needs to be done in order to prevent the delayed development of fatal complications.

The decomposed body of a woman discovered beneath a collapsed structure was examined at the C.A. Pound Human Identification Laboratory. Despite a mix of rib fractures with and without indications of healing, it is most likely that all fractures occurred as a result of a single, compressive event. Signs of intramembranous, and possibly direct, fracture healing at the incomplete fractures without signs of endochondral ossification at the complete fractures suggest the individual died very shortly-but not immediately-after injury. Given the case circumstances, the findings inform immediate cause of death. This case study highlights that differential healing as a result of a single event is possible. Further, it illustrates the importance of careful examination of micro-discontinuities/cracks that can occur in association with major fractures. Fracture healing and dating data are discussed, as is the possible need for critical evaluation of the antemortem/perimortem boundary., (© 2018 American Academy of Forensic Sciences.)

Forensic imaging technology has rapidly advanced over the past several decades and is gaining increasing significance in medico-legal death investigations. Medical-grade computed tomography (CT) is now routinely used in post-mortem examinations at numerous institutions across the globe. However, the resolution of medical-grade CT is limited and unsuitable when used to depict some smaller anatomical structures or micro-trauma. High-resolution micro-CT offers up to 100× the resolution to overcome this problem but is a very recent addition to the field of forensic radiology. Few studies so far have attempted to validate the results which is an essential prerequisite for it to be used in the criminal justice process as demanded by regulatory bodies. This study directly compares micro-CT images with histology, the current gold standard. Three cases were examined: two larynges from suspected strangulations and one ribcage of a case of fatal child abuse. A strong correlation was observed between histology and micro-CT as the majority of skeletal injuries were identified correctly. This paper discusses the forensic implications of the results and how micro-CT is complementary to histology., (Copyright © 2019 The Authors. Published by Elsevier B.V. All rights reserved.)

Traumatic rib fracture can cause severe pain and is usually associated with the depression of respiratory drive followed by severe respiratory complications. It is critical for patients with rib fracture to receive adequate analgesia. However, strong opioids and other analgesics often produces side effects and may even cause respiratory suppression. Meanwhile, rib fixation now has become a popular method for treating rib fracture patients. However, the actual molecular mechanism leading to its effectiveness as an analgesia has not been fully investigated, and the best analgesic method for its use in rib fracture patients has not yet been determined. We developed a new animal model for rib fracture and evaluated changes in pain severity after rib fixation. Our data indicated significantly better analgesic behavior if a soft string rib fixation is performed, which is associated with cytokine (interleukine-6 and interleukine-10) decreases in the spinal cord and co-localization with glia cells. Our results provided a treatment suggestion for rib fracture patients and the possible molecular mechanism for the analgesic effects. Further molecular mechanisms and the best therapeutic methods are still needed for this severe painful condition.

Literature on timing of rib trauma is scarce but remains challenging during forensic cases. This study analysed the macroscopic fracture patterns of perimortem rib fractures and compared them to experimentally reproduced rib fractures on fresh and dry ribs. Six distinctive macroscopic traits were found in ribs that might provide information about the timing of trauma, fracture mechanism and/or trauma circumstances. These traits are peels, folds, differential fracture edges, incomplete fractures, plastic deformation and longitudinal lines. Peels, folds and plastic deformation might provide information about trauma timing. Folds and different fracture edges might provide information about the fracture mechanism. Statistical analyses showed that longitudinal lines, folds and incomplete fractures might provide information about the trauma circumstances and that age might have an influence on the occurrence of complete fractures, longitudinal lines and peels (p ≤ 0.05). The new insights presented in this study might be valuable for forensic anthropologists in rib trauma analysis.

Objectives:  To characterize the clinical features among dogs sustaining rib fractures and to determine if age, type and severity of injury, entry blood lactate, trauma score and rib fracture score were associated with outcome., Methods:  A retrospective study was performed to include dogs that were presented with rib fractures. Risk factors evaluation included breed, age, body weight, diagnosis, presence of a flail chest, bandage use, puncture wound presence, rib fracture number, location of the fracture along the thoracic wall, hospital stay length, body weight, other fractures, pleural effusion, pulmonary contusions, pneumothorax and occurrence of an anaesthetic event. A retrospective calculation of an animal trauma triage (ATT) score, RibScore and Modified RibScore was assigned., Results:  Forty-one medical records were collected. Motor vehicular trauma represented 56% of the rib fracture aetiology, 41% of patients sustained dog bites and one case was of an unknown aetiology. Significant correlations with risk factors were found only with the ATT score. All patients that died had an ATT score ≥ 5. The ATT score correlated positively with mortality ( p  < 0.05) with an ATT score ≥ 7 was 88% sensitive and 81% specific for predicting mortality. A 1-point increase in ATT score corresponded to 2.1 times decreased likelihood of survival. Mean hospital stay was 3 days longer for dog bite cases., Clinical Significance:  There was no increased mortality rate in canine patients that presented with the suspected risk factors. The only risk factor that predicted mortality was the ATT score., Competing Interests: None., (Georg Thieme Verlag KG Stuttgart · New York.)

Although many clinical trials have demonstrated its efficacy during active compression-decompression cardiopulmonary resuscitation (ACD-CPR), the Ambu® CardioPump seems likely to cause severe and sometimes lethal injuries. In this paper, we report two cases observed at the Institute of Legal Medicine of Nancy, France. A 67-year-old man collapsed in the street, in the presence of witnesses, and without any sign of trauma. The autopsy revealed a flail chest, a wound of the left ventricle, a rupture of the right ventricle, and a wrenching of the inferior vena cava. A 71-year-old woman was found in her apartment during an accidental fire. The autopsy revealed a sternal fracture, many rib fractures, and a perforation of the superior vena cava, the pericardium, and the heart. Despite articles focusing on complications of the use of the CardioPump in the late 1990s, this technique is still used in practice. These two cases emphasize that iatrogenic injuries must be taken into account in the CardioPump benefit/risk balance and the relevance of its daily use.

Several patients suffer from rib fractures after traumas, and in severe cases it can be life-threatening. Until recently, attempts to perform surgical fixation in patients with instability have been unsuccessful. Chronic non-union causes persistent pain, disability and loss of quality of life. Implementation of surgical stabilization of rib fractures with tailored plates seems to improve pain relief, especially in cases of non-union but also in patients with instability of the chest wall after severe traumas, where advanced pain treatment (epidural catheter) is insufficient or weaning off fails.

Objective: Field data analyses often use either parametric or nonparametric means to describe the relationship between risk and various predictor variables. This study sought to evaluate a hybrid approach using semiconstrained multivariate nonlinear spline-based analysis., Methods: Data were compiled from NASS-CDS years 1998-2015, selecting belted occupants age 16+ in collisions with a principal direction of force (PDOF) from 10 o'clock to 2 o'clock. Outcome measures included the incidence of Maximum Abbreviated Injury Scale (MAIS) 3+ injury in general and Abbreviated Injury Scale (AIS) 3+ rib fracture injury. Multivariate logistic regression models were fit controlling for PDOF, ΔV, vehicle model year, collision year, occupant age, occupant body mass index (BMI), and other select factors. Within the logistic regression models, each of the continuous variables was modeled with a 4-knot spline. These were compared to models treating ΔV and BMI linearly., Results: A total of 29,667 occupants were observed from the query, representing approximately 13,608,398 occupants when weighted. Sixty percent of the AIS 3+ rib fracture cases occurred at ΔVs at or below 40 km/h. The median age for cases without AIS 3+ rib fracture was 34 years old. The median age for cases with AIS 3+ rib fracture was 62 years old. When modeled via nonlinear spline, the risk of MAIS 3+ injury in general and AIS 3+ rib fracture injury specifically exhibited a relationship with ΔV similar in shape to that observed in the linear model. In both cases, the spline model exhibited greater risk prediction over ΔVs from 25 to 50 km/h compared to the linear model (20-33% greater risk at ΔVs below 40 km/h) and less risk than the linear model at greater ΔVs. BMI exhibited a nonlinear, nonmonotonic relationship with both injury types studied. The risk tended to be a minimum at BMIs of 22-24 kg/m 2 , with an increase in risk at both higher and lower BMIs. For AIS 3+ rib fracture, the risk for a person with a BMI of 18 was approximately equal to the risk for a person with a BMI of 30, both being approximately 40% greater than the risk associated with a BMI of 24., Conclusions: Nonlinear multivariate regression methods have the potential to convey information about the risk-predictor relationship that cannot be captured through traditional linear modeling. These results suggest that traditional linear logistic regression models may underestimate the risk of AIS 3+ rib fracture injury in the ΔV range where they most frequently occur (below 50 km/h). Due to its nonmonotonic effect, traditional linear models may underestimate injury risk at both high and low BMIs.

Aim: To determine the frequency of cardiopulmonary resuscitation (CPR)-related injuries and factors involved in their occurrence, data based on forensic autopsy and postmortem computed tomography (PMCT) during implementation of the 2010 American Heart Association Guidelines for CPR were studied., Methods: We retrospectively evaluated data on adult patients with non-traumatic deaths who had undergone manual CPR and autopsy from January 2012 to December 2014. CPR-related injuries were analyzed on autopsy records and PMCT images and compared with results of previous studies., Results: In total, 180 consecutive cases were analyzed. Rib fractures and sternal fractures were most frequent (overall frequency, 66.1 and 52.8%, respectively), followed by heart injuries (12.8%) and abdominal visceral injuries (2.2%). Urgently life-threatening injuries were rare (2.8%). Older age was an independent risk factor for rib fracture [adjusted odds ratio (AOR), 1.06; 95% confidence interval (CI), 1.04-1.08; p < 0.001], ≥ 3 rib fractures (AOR, 1.06; 95% CI, 1.02-1.09; p = 0.002), and sternal fracture (AOR, 1.03; 95% CI, 1.01-1.05; p < 0.001). Female sex was significantly associated with sternal fracture (AOR, 2.08; 95% CI, 1.02-4.25; p = 0.04). Chest compression only by laypersons was inversely associated with rib and sternal fractures. Body mass index and in-hospital cardiac arrest were not significantly associated with any complications. The frequency of thoracic skeletal injuries was similar to that in recent autopsy-based studies., Conclusions: Implementation of the 2010 Guidelines had little impact on the frequency of CPR-related thoracic skeletal injuries or urgently life-threatening complications. Older age was the only independent factor related to thoracic skeletal injuries.

Background  Rib fracture is the most common result of thoracic traumas. Intrapulmonary shunt, alveolar capillary membrane damage, intra-alveolar hemorrhage, and hypoxia may develop following rib fractures. Therefore, prompt treatment is important. The aim of this experimental study was to analyze the effects of platelet-rich plasma (PRP) on rib fractures to secure a speedier and more efficient treatment method. Materials and Methods  The study involved 18 New Zealand white rabbits, randomly divided into three groups as Group 1, the sham group with no surgical intervention; Group 2, the control group in which simple rib fractures were applied and no treatment; and Group 3, in which rib fractures were applied and then PRP treatment was administered. Results  The mean recovery plate thickness measurements were found to be statistically significantly higher in the PRP group compared with the other groups ( p  < 0.005). A thicker fibrotic cell proliferation and the formation of many capillaries were observed around the growth plate in the PRP group compared with the other groups. These structures were lesser in the control group compared with the PRP group and at the lowest level in the sham group. Larger and distinct callus formation was observed and a new intramedullary field in the PRP group. Conclusions  PRP is a reliable and effective autologous product with minimal side effects, which can be considered as an alternative treatment in patients with rib fractures and used easily in pseudoarthrosis, surgical fracture, or flail chest., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Georg Thieme Verlag KG Stuttgart · New York.)

Following the death of a woman with blunt force chest trauma, the question was asked how common was the finding at autopsy of a flail chest in decedents after failed cardiopulmonary resuscitation. It was suggested in court that this was an uncommon occurrence. To address this issue, autopsy cases in adults (>18 years) with rib fractures attributable to cardiopulmonary resuscitation were taken from the files of Forensic Science SA over a 7-year period from 2008 to 2014. Flail chest injuries were defined as those arising from fractures at two sites in at least three consecutive ribs. From 236 cases with rib fractures attributed to resuscitation, a total of 43 flail chest injuries were found in 35 cases (14.8%). The majority occurred in the 60-79-year-old age group. These data suggest that flail chest injuries are a more common sequelae of cardiopulmonary resuscitation than has been previously appreciated in autopsy cases, particularly in the elderly., (© 2017 American Academy of Forensic Sciences.)

Purpose: The purpose of this study was to assess the effects of recent surgical rib fixation and establish its indications not only for flail chest but also for multiple rib fractures., Methods: Between 2007 and 2015, 187 patients were diagnosed as having multiple rib fractures in our institution. After the propensity score matching was performed, ten patients who had performed surgical rib fixation and ten patients who had treated with non-operative management were included. Categorical variables were analyzed with Fischer's exact test and non-parametric numerical data were compared using the Mann-Whitney U test. Wilcoxon signed-rank test was performed for comparison of pre- and postoperative variables. All statistical data are presented as median (25-75 % interquartile range [IQR]) or number., Results: The surgically treated patients extubated significantly earlier than non-operative management patients (5.5 [1-8] vs 9 [7-12] days: p = 0.019). The duration of continuous intravenous narcotic agents infusion days (4.5 [3-6] vs 12 [9-14] days: p = 0.002) and the duration of intensive care unit stay (6.5 [3-9] vs 12 [8-14] days: p = 0.008) were also significantly shorter in surgically treated patients. Under the same ventilating conditions, the postoperative values of tidal volume and respiratory rate improved significantly compared to those values measured just before the surgery. The incidence of pneumonia as a complication was significantly higher in non-operative management group (p = 0.05)., Conclusions: From the viewpoints of early respiratory stabilization and intensive care unit disposition without any complications, surgical rib fixation is a sufficiently acceptable procedure not only for flail chest but also for repair of severe multiple rib fractures.

Objective: To describe the clinical presentation and outcome of known attacks in client-owned dogs caused by the common coyote, Canis latrans., Design: Retrospective observational study., Setting: Private referral hospital., Animals: One hundred fifty-four client-owned dogs known to be attacked by coyotes., Interventions: None., Measurements and Main Results: Records from a private referral hospital from May 1997 through December 2012 were reviewed. Time of day and month/season of year, signalment, body temperature, heart rate, respiratory rate, body weight, location and severity of wounds inflicted, common injuries, length of hospitalization, necessity of surgical wound repair under anesthesia, antimicrobial use and mortality were recorded. Eighty-six percent of dogs presenting following coyote attack weighed <10 kg. Overall mortality rate was 15.6%. Dogs with bite wounds to the thorax had the highest mortality at 21.3%. Criteria for systemic inflammatory response syndrome (SIRS) based on admission vital signs were met in 58.8% of dogs and the presence of SIRS was significantly associated with mortality (P < 0.001). Common coyote-induced injuries included rib fracture (38/154; 24.6%), pulmonary contusion (30/154; 19.4%), tracheal tear (18/154; 11.6%), pneumothorax (16/154; 10.3%), abdominal wall hernia (9/154; 5.8%), and abdominal penetrating wounds (8/146; 5.5%). Dogs <10 kg were significantly more likely to incur wounds to multiple body parts or sustain abdominal penetrating wounds. The presence of rib fracture was significantly associated with mortality. Frequency of coyote attacks over the time of this study increased by 330%., Conclusions: Coyote attacks on dogs are a problem in Southern California and are associated with substantial morbidity and mortality, especially in dogs with wounds to the thorax. Aggressive management involving surgical wound repair was associated with survival to discharge., (© Veterinary Emergency and Critical Care Society 2017.)

Purpose: The aim of this multi-reader feasibility study was to evaluate new post-processing CT imaging tools in rib fracture assessment of forensic cases by analyzing detection time and diagnostic accuracy., Materials and Methods: Thirty autopsy cases (20 with and 10 without rib fractures in autopsy) were randomly selected and included in this study. All cases received a native whole body CT scan prior to the autopsy procedure, which included dissection and careful evaluation of each rib. In addition to standard transverse sections (modality A), CT images were subjected to a reconstruction algorithm to compute axial labelling of the ribs (modality B) as well as "unfolding" visualizations of the rib cage (modality C, "eagle tool"). Three radiologists with different clinical and forensic experience who were blinded to autopsy results evaluated all cases in a random manner of modality and case., Results: Rib fracture assessment of each reader was evaluated compared to autopsy and a CT consensus read as radiologic reference. A detailed evaluation of relevant test parameters revealed a better accordance to the CT consensus read as to the autopsy. Modality C was the significantly quickest rib fracture detection modality despite slightly reduced statistic test parameters compared to modalities A and B., Conclusion: Modern CT post-processing software is able to shorten reading time and to increase sensitivity and specificity compared to standard autopsy alone. The eagle tool as an easy to use tool is suited for an initial rib fracture screening prior to autopsy and can therefore be beneficial for forensic pathologists.

Introduction: It is unknown whether the magnitude of rib fracture (RF) displacement predicts pain medication requirements in blunt chest trauma patients., Methods: Adult blunt RF patients undergoing computed tomography (CT) of the chest admitted to an urban Level 1 trauma center (2007-2012) were retrospectively reviewed. Pain management in those with displaced RF (DRF), nondisplaced RF (NDRF), or combined DRF and NDRF (CRF) was compared by univariate analysis. Linear regression models were developed to determine whether total opioid requirements [expressed as log morphine equianalgesic dose (MED)] could be predicted by the magnitude of RF displacement (expressed as the sum of the Euclidean distance of all displaced RF) or number of RF, after adjusting for patient and injury characteristics., Results: There were 245 patients, of whom 39 (16%) had DRF only, 77 (31%) had NDRF only, and 129 (53%) had CRF. Opioids were given to 224 patients (91%). Compared to DRF (mean, 1.7 RF per patient) and NDRF patients (2.4 RF per patient), those with CRF (6.8 RF per patient) were older and had more RF per patient and a higher Injury Severity Score (ISS) and MED (251 vs 53 and 105 mg, respectively, p < 0.0001 and p = 0.0045). They also more frequently received patient-controlled analgesia. Patients with displaced RF had a lower mean ISS and MED and received more epidural analgesia compared with patients with NDRF. Total MED was associated with both the magnitude of RF displacement (p < 0.0001) and the number of RF (p < 0.0001). Every 5-mm increase in total displacement predicted a 6.3% increase in mean MED (p = 0.0035), while every additional RF predicted an 11.2% increase in MED (p = 0.0001). These associations included adjustment for age, ISS, and presence of chest tubes., Conclusion: The magnitude of RF displacement and the number of RF predicted opioid requirements. This information may assist in anticipating patients with blunt RF who might have higher analgesic requirements., Level of Evidence: Therapeutic study, level IV., Competing Interests: There are no conflicts of interest to declare

Background: A pseudohernia is an abdominal wall bulge that may be mistaken for a hernia but that lacks the disruption of the abdominal wall that characterizes a hernia. Thus, the natural history and treatment of this condition differ from those of a hernia. This is the first report of a pseudohernia due to cough-associated rib fracture., Case Presentation: A case of pseudohernia due to fractures of the 10 th and 11 th ribs in a 68-year-old white woman is presented. The patient suffered from a major coughing episode 1 year prior to her presentation, after which she noted a progressively enlarging bulge in her left flank. Computed tomography demonstrated a bulge in the abdominal wall containing bowel and spleen but with all muscle and fascial layers intact; in addition, lateral 10 th rib and posterior 11 th rib fractures were noted., Conclusions: As there was no defect in muscle or fascia, we diagnosed a pseudohernia, likely due to a denervation injury from the fractured ribs. Symptomatic treatment was recommended, including wearing a corset and referral to a pain management clinic. Symptomatic treatment is thought to be the mainstay of therapy for pseudohernias, as surgical intervention is unlikely to be of benefit.

Fatalities caused by cattle occur relatively often in rural areas and mostly show sharp and blunt injuries. In the presented case, a 61-year-old farmer was found dead in a cowshed together with an untied bull. Autopsy revealed severe hemorrhages and massive chest trauma with multiple bilateral rib fractures. The cause of death was severe chest trauma. In the presented case, death was not brought about by the bull's horns but by butts to the man's chest.

A 38-year-old black woman with a medical history significant for hypertension and depression presented to the emergency department with a 2-week history of lower back pain. This visit was her second in 1 week with the same symptoms, after attaining minimal pain relief with cyclobenzaprine., (Copyright © 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Displacement patterns of rib fractures (RF) and their association with thoracic coinjuries and outcomes are unknown. This is a retrospective review of adult patients with blunt closed RF who underwent chest CT at a Level I trauma center (2007-2012). Displacement patterns of RF were compared among the three-dimensional planes using CT images. An analysis of receiver operating characteristic (ROC) curves was performed to identify displacements in each plane most strongly associated with chest coinjuries. Univariate analysis was used to find association of displaced RF with hospital course and outcome. There were 1127 RF (245 patients, most in ribs 3-9, 45 per cent displaced). Axial displacement was the most common, with odds ratios 7.20 and 2.13 compared with cranio-caudal, and impaction-separation (along rib axis) movement, respectively. Axial displacement thresholds performed well with hemothorax (2.8 mm, ROC = 0.74), pneumothorax (2.6 mm, ROC = 0.70), hemopneumothorax (3.1 mm, ROC = 0.77), flail chest (3.4 mm, ROC = 0.80), and chest tube placement (2.8 mm, ROC = 0.75). RF displacement was associated with increased days on mechanical ventilation and hospital length of stay. In conclusion, even minimal RF displacement is associated with increased risk of chest coinjuries and chest tube placement, and displacements correlated with increased days on mechanical ventilation and hospital length of stay. Future studies are required to investigate these associations, especially in relationship to the indications for rib plating.

Introduction: Compressive rib fractures are considered to be indicative of non-accidental injury (NAI) in infants, which is a significant and growing issue worldwide. The diagnosis of NAI is often disputed in a legal setting, and as a consequence there is a need to model such injuries ex vivo in order to characterise the forces required to produce non-accidental rib fractures. However, current models are limited by type of sample, loading method and rate of loading. Here, we aimed to: i) develop a loading system for inducing compressive fractures in whole immature ribs that is more representative of the physiological conditions and mechanism of injury employed in NAI and ii) assess the influence of loading rate and rib geometry on the mechanical performance of the tissue., Methods: Porcine ribs (5-6 weeks of age) from 12 animals (n=8 ribs/animal) were subjected to axial compressive load directed through the anterior-posterior rib axis at loading rates of 1, 30, 60 or 90 mm/s. Key mechanical parameters (including peak load, load and percentage deformation to failure and effective stiffness) were quantified from the load-displacement curves. Measurements of the rib length, thickness at midpoint, distance between anterior and posterior extremities, rib curvature and fracture location were determined from radiographs., Results: This loading method typically produced incomplete fractures around the midpoint of the ribs, with 87% failing in this manner; higher loads and less deformation were required for ribs to completely fracture through both cortices. Loading rate, within the range of 1-90 mm/s, did not significantly affect any key mechanical parameters of the ribs. Load-displacement curves displaying characteristic and quantifiable features were produced for 90% of the ribs tested, and multiple regression analyses indicate that, in addition to the geometrical variables, there are other factors such as the micro- and nano-structure that influence the measured mechanical data., Conclusions: A reproducible method of inducing fractures in a consistent location in immature porcine ribs has been successfully developed. Fracture appearance may be indicative of the amount of load and deformation that produced the fracture, which is an important finding for NAI, where knowledge of the aetiology of fractures is vital. Characteristic rib behaviour independent of loading rate and, to an extent, rib geometry has been demonstrated, allowing further investigation into how the complex micro- and nano-structure of immature ribs influences the mechanical performance under compressive load. This research will ultimately enable improved characterisation of the loading pattern involved in non-accidental rib fractures., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

The human rib cage resembles a masonry dome in shape. Masonry domes have a particular construction that mimics stress distribution. Rib cortical thickness and bone density were analyzed to determine whether the morphology of the rib cage is sufficiently similar to a shell dome for internal rib structure to be predicted mathematically. A finite element analysis (FEA) simulation was used to measure stresses on the internal and external surfaces of a chest-shaped dome. Inner and outer rib cortical thickness and bone density were measured in the mid-axillary lines of seven cadaveric rib cages using computerized tomography scanning. Paired t tests and Pearson correlation were used to relate cortical thickness and bone density to stress. FEA modeling showed that the stress was 82% higher on the internal than the external surface, with a gradual decrease in internal and external wall stresses from the base to the apex. The inner cortex was more radio-dense, P < 0.001, and thicker, P < 0.001, than the outer cortex. Inner cortical thickness was related to internal stress, r = 0.94, P < 0.001, inner cortical bone density to internal stress, r = 0.87, P = 0.003, and outer cortical thickness to external stress, r = 0.65, P = 0.035. Mathematical models were developed relating internal and external cortical thicknesses and bone densities to rib level. The internal anatomical features of ribs, including the inner and outer cortical thicknesses and bone densities, are similar to the stress distribution in dome-shaped structures modeled using FEA computer simulations of a thick-walled dome pressure vessel. Fixation of rib fractures should include the stronger internal cortex., (© 2015 Wiley Periodicals, Inc.)

The development of advanced injury prediction models requires biomechanical and injury tolerance information for all regions of the body. While numerous studies have investigated injury mechanics of the thorax under frontal impact, there remains a dearth of information on the injury mechanics of the torso under blunt impact to the back. A series of hub-impact tests were performed to the back surface of the mid-thorax of four mid-size male cadavers. Repeated tests were performed to characterize the biomechanical and injury response of the thorax under various impact speeds (1.5m/s, 3m/s and 5.5m/s). Deformation of the chest was recorded with a 59-gage chestband. Subject kinematics were also recorded with a high-speed optoelectronic 3D motion capture system. In the highest-severity tests, peak impact forces ranged from 6.9 to 10.5 kN. The peak change in extension angle measured between the 1st thoracic vertebra and the lumbar spine ranged from 39 to 62°. The most commonly observed injuries were strains of the costovertebral/costotransverse joint complexes, rib fractures, and strains of the interspinous and supraspinous ligaments. The majority of the rib fractures occurred in the rib neck between the costovertebral and costotransverse joints. The prevalence of rib-neck fractures suggests a novel, indirect loading mechanism resulting from bending moments generated in the rib necks caused by motion of the spine. In addition to the injury information, the biomechanical responses quantified here will facilitate the future development and validation of human body models for predicting injury risk during impact to the back., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Aim: The aim of our study was to compare traumatic injuries observed after cardiopulmonary resuscitation (CPR) by means of standard (manual) or assisted (mechanical) chest compression by Lund University Cardiopulmonary Assist System, 2nd generation (LUCAS2) device., Methods: A retrospective study was conducted including cases from 2011 to 2013, analysing consecutive autopsy reports in two groups of patients who underwent medicolegal autopsy after unsuccessful CPR. We focused on traumatic injuries from dermal to internal trauma, collecting data according to a standardised protocol., Results: The study group was comprised of 26 cases, while 32 cases were included in the control group. Cardiopulmonary resuscitation performed by LUCAS2 was longer than manual CPR performed in control cases (study group: mean duration 51.5 min; controls 29.4 min; p = 0.004). Anterior chest lesions (from bruises to abrasions) were described in 18/26 patients in the LUCAS2 group and in 6/32 of the control group. A mean of 6.6 rib fractures per case was observed in the LUCAS2 group, but this was only 3.1 in the control group (p = 0.007). Rib fractures were less frequently observed in younger patients. The frequency of sternal factures was similar in both groups. A few trauma injuries to internal organs (mainly cardiac, pulmonary and hepatic bruises), and some petechiae (study 46%; control 41 %; p = 0.79) were recorded in both groups., Conclusion: LUCAS™2-CPR is associated with more rib fractures than standard CPR. Typical round concentric skin lesions were observed in cases of mechanical reanimation. No life-threatening injuries were reported. Petechiae were common findings.

Although components of the renin-angiotensin system (RAS) are reported to be expressed in cultured chondrocytes and cartilage, little is known about the precise function of Angiotensin II (Ang II) in chondrocytes. In this study, we employed a rib fracture model mouse to investigate the effect of Ang II on chondrocytes. Ang II type 1 receptor (AT1R) was expressed in chondrocytes in the growth plate of mouse tibia. Continuous infusion of Ang II to rib-fractured mice resulted in a significant increase in the volume of cartilage, suggesting Ang II-induced hypertrophic differentiation of chondrocytes. It was also confirmed by a significant increase in the mRNA expression of Sox9 and runt-related transcription factor 2 (Runx2), which are genes related to chondrocyte differentiation, and type X collagen, matrix metalloproteinase (MMP)-13 and Indian hedgehog (Ihh), which are hypertrophic chondrocyte-specific molecular markers. Chondrocyte hypertrophy with upregulation of these genes was attenuated by administration of olmesartan, an AT1R blocker, but not by hydralazine. Moreover, Ang II infusion significantly suppressed apoptosis of chondrocytes, accompanied by significant induction of mRNA expression of bcl-2 and bcl-xL. Olmesartan, but not hydralazine, significantly attenuated the reduction of apoptotic cells and the increase in anti-apoptotic genes induced by Ang II infusion. Overall, the present study demonstrated that Ang II promoted hypertrophic differentiation of chondrocytes and reduced apoptosis of hypertrophic chondrocytes independently of high blood pressure. The present data indicate the role of Ang II in cartilage, and might provide a new concept for treatment of cartilage diseases.

Cardiac injuries may rarely be observed due to blunt thoracic traumas. Cardiac injury often creates a life-threatening condition requiring urgent surgical intervention, and follow-up of these patients should be carefully carried out in the perioperative period. These injuries depend on various factors including clinical presentation, type of injury, the time that passes until the patient reaches the hospital, bleeding, cardiac tamponade, or additional injuries. This article aimed to report a case who suffered penetrating cardiac injury in blunt thoracic trauma. Evaluated in the emergency department due to a motor vehicle accident, the 61-year-old male patient's chest x-ray revealed pulmonary contusion, rib fractures and cardiac tamponade. The patient was operated emergently. Right atrial injury was observed in the operation. The cardiac injury was repaired with primary suture technique. Cardiac injury in patients with blunt thoracic trauma is likely to be observed. In these patients, careful physical examination, early diagnosis, and treatment are very important.

Pediatric rib head fractures are typically described as "posterior" or "costovertebral," terms lacking specificity. To resolve this issue, a scheme was developed to describe the location of rib head fractures observed in a pediatric forensic population. The scheme uses three anatomical landmarks, terminus (tip), tubercle, and costovertebral articular surface to divide the rib head into two subregions, costovertebral and costotransverse. Examples of five cases of infants with rib head fractures are presented using this scheme. Forty-eight rib head fractures were observed in these infants with the following frequencies: 56% (three infants) at the terminus; 21% (three infants) in the costovertebral subregion; 21% (one infant) at the costovertebral articular facet; and 2% (one infant) in the costotransverse subregion. Due to the small number of cases assessed, statistical analyses could not be performed; however, the data demonstrate the variation in distribution of pediatric rib head fractures., (© 2014 American Academy of Forensic Sciences.)

Rib stress injuries are uncommonly reported but have been documented among athletes, most notably rowers. There have only been two prior case reports of rib stress injuries in swimmers, both of which were young females. Magnetic resonance (MR) imaging was either not obtained or the imaging characteristics were incompletely described. We present a case of an isolated third rib stress injury in a collegiate male swimmer diagnosed via MR imaging. We briefly discuss the possible etiologies for rib stress injuries, their MR appearance, as well as their treatment.

Current autopsy practice in forensic pathology is to a large extent based on experience and individual customary practices as opposed to evidence and consensus based practices. As a result there is the potential for substantial variation in how knowledge is applied in each case. In the present case series, we describe the variation observed in autopsy reports by five different pathologists of eight victims who died simultaneously from traumatic asphyxia due to compression during a human stampede. We observed that there was no mention of the availability of medical charts in five of the reports, of potentially confounding resuscitation efforts in three reports, of cardinal signs in seven reports and of associated injuries to a various degree in all reports. Further, there was mention of supplemental histological examination in two reports and of pre-autopsy radiograph in six reports. We inferred that reliance on experience and individual customary practices led to disparities between the autopsy reports as well as omissions of important information such as cardinal signs, and conclude that such reliance increases the potential for error in autopsy practice. We suggest that pre-autopsy data-gathering and the use of check lists specific to certain injury causes are likely to result in less deviation from evidence-based practices in forensic pathology. Pre-autopsy data-gathering and check lists will help ensure a higher degree of standardization in autopsy reports thus enhancing the quality and accuracy of the report as a legal document as well as rendering it more useful for data-gathering efforts., (Copyright © 2013 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

These days we have fast paced traffic on our roads to help us keep up with our fast paced life. But every boon has a down side and our high velocity traffic is no exception. Here is a case report of a blunt abdominal injury following a road traffic accident. Externally the deceased had only a few grazed abrasions on the forehead and right forearm. But on internal examination of abdomen, it was noticed that the left hemi-diaphragm was torn and the stomach and intestines were found displaced into the left thoracic cavity., (Copyright © 2013 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)